Medical Management v4.0 (AHM-540)

Demetrius Farrell, age 82, is suffering from a terminal illness and has consulted his health plan about the care options available to him. In order to avoid unwanted, futile interventions, Mr. Farrell signed an advance directive that indicates the types of end-of-life medical treatment he wants to receive. His family is to use this document as a guide should
Mr. Farrell become incapacitated.
For this question, if answer choices (A) through (C) are all correct, select answer choice
(D). Otherwise, select the one correct answer choice.
Decisions regarding Mr. Farrells end-of-life care are legally the right and responsibility of

For this question, if answer choices (A) through (C) are all correct, select answer choice
(D). Otherwise, select the one correct answer choice.
The QAPI (Quality Assessment Performance Improvement Program) is a Centers for
Medicaid and Medicare Services (CMS) initiative designed to strengthen health plans efforts to protect and improve the health and satisfaction of Medicare beneficiaries. QAPI quality assessment standards apply to

The paragraph below contains two pairs of terms or phrases enclosed in parentheses.
Determine which term or phrase in each pair correctly completes the paragraph. Then select the answer choice containing the two terms or phrases that you have selected.
The process for collecting and analyzing data differs for quality assessment (QA) and quality improvement (QI). For QA, data collection focuses on (objective / both objective and subjective) data, and data analysis identifies the (degree / cause) of variance.

One difference between outcomes research and clinical research is that outcomes research

Helena Ray, a member of the Harbrace Health Plan, suffers from migraine headaches. To treat Ms. Rays condition, her physician has prescribed Upzil, a medication that has Food and Drug Administration (FDA) approval only for the treatment of depression. Upzil has not been tested for safety or effectiveness in the treatment of migraine headache. Although
Harbraces medical policy for migraine headache does not include coverage of Upzil,
Harbrace has agreed to provide extra-contractual coverage of Upzil for Ms. Ray.
In this situation, the prescribing of Upzil for Ms. Rays headaches is an example of

Patient safety and medical errors are important concerns for both quality management
(QM) and risk management. The following statement(s) can correctly be made about medical errors:
1.The complexity of modern medicine and healthcare delivery systems increases patients exposure to the risks of medical errors
2.Licensing boards for healthcare professionals in all states provide a consistent system of quality oversight and accountability
3.Provider compliance with internal incident reporting requirements is low

The paragraph below contains two pairs of phrases enclosed in parentheses. Select the phrase in each pair that correctly completes the paragraph. The select the answer choice containing the two phrases you have selected.
Calvin Montrose, age 75, has difficulty performing basic self-care activities, such as bathing, dressing, and eating, without assistance. This information indicates that Mr.
Montrose needs assistance with (activities of daily living / instrumental activities of daily living) that are used to measure his (functional status / health status).

DUR can be conducted prospectively, concurrently, or retrospectively. One true statement about prospective DUR is that it

State governments serve as both regulators and purchasers of health plan services. The influence of state governments as purchasers is focused on

The following statements are about health plans development of medical policies. Three of the statements are true and one is false. Select the answer choice containing the FALSE statement.

One way that health plans can make their benefits more appealing to employers and employees is to offer coverage for specialty services. It is correct to say that specialty services typically

Skilled nursing facilities (SNFs) are required by law to have formal programs for quality improvement and to monitor these programs using established standards. These requirements are described in
1.The Omnibus Budget Reconciliation Act (OBRA) of 1986
2.The Balanced Budget Act (BBA) of 1997

The Shoreside Health Plan recently added coverage for behavioral healthcare services to its benefit package. In order to support the quality of its behavioral healthcare services,
Shoreside plans to seek accreditation for its behavioral healthcare program. Accreditation specifically designed for behavioral healthcare programs is available through
1.The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
2.The National Committee for Quality Assurance (NCQA)
3.The American Accreditation HealthCare Commission/URAC (URAC)

One of the steps in drug utilization review (DUR) is defining optimal drug use, which can be accomplished by applying diagnosis criteria and drug-specific criteria. Drug-specific criteria are standards that identify the

This agency oversees fraud and abuse matters as they relate to medical management.